It was Friday afternoon and I was waiting for my last appointment of the week, a patient named Michelle referred by the probation department for alcoholism counselling. I sipped coffee as I tried to pull information from the sketchy referral form. About all I learned was that Michelle Picou was on probation for physical assault in a neighbor-hood bar. I wondered what sort of wild woman I was about to meet.
The buzzer on the waiting room door sounded and I went to meet Michelle. In the waiting room I found an attractive woman dressed in shorts and a blouse, and a short person wearing paint-specked blue jeans, a blue work shirt, and a greasy baseball cap. Their appearance confused me because the woman in shorts didn’t look violent and the other person didn’t look like a Michelle. Without thinking, I held out my hand to the attractive woman and said, “Michelle my name is John.”
“I’m Michelle,” said the other person in a pseudo-gruff voice.
Realizing my mistake, I quickly turned and said, “Excuse me Michelle, my name is John. Won’t you come inside?”
She replied, “Sure, why not.”
In my office I offered Michelle a seat and asked if she would like a cup of coffee. She politely declined the coffee and handed me a large brown envelope containing background information and her arrest record. Then she abruptly stated that her friend’s name was Barbara and they were living together. Since sexual orientation is not a disorder, I simply remarked that Barbara seemed to be a nice person. However Michelle was determined to discuss their relationship and she defiantly announced that she was a lesbian. She was daring me to make something of it and I realized that she had to know if I had a problem with homosexuality before she could trust me. I calmly told her that my concern involved her referral for alcoholism counselling and assured her that I was not judgemental about relationships. But I also let her know that we would talk about her relationship if it was related to her drinking.
She stared at me with pale blue eyes, not totally convinced that I was telling the truth. She had removed her cap and I could see that she had short blonde hair and a slightly narrow face. I noticed that her teeth were tightly clinched and the muscles of her jaw were tense, causing her otherwise attractive face to appear distorted. It seemed obvious to me that sexual orientation was related to some kind of stress in her life and I wanted her to know that I did not intend to be part of that stress. Establishing rapport with Michelle, I thought, might be difficult. I began by explaining to her that therapy would involve a lot of talking. I told her we would review her history so we could identify any issues related to alcohol abuse and develop ways for her to deal with them. She continued to stare at me without acknowledging my explanation. I then offered some consent forms, which she signed without comment.
I asked her to start by describing the events that led to her probation and referral for alcohol treatment. She said the problem began at work. She has worked at an automobile paint shop as a painter for the past three years. The other painters in the shop are men, most of whom were uncomfortable when they first learned that “Mitch” was a woman. They eventually got used to her but some were irritated when she became a painter. After Barbara moved in with her another problem arose. Someone in the shop found out they were living together and one of the men began making jokes about lesbians. Michelle said she managed to ignore the jokes and insults for several months but as other men joined in she became more and more irritated. She wanted to confront her tormentors but she was afraid her anger might get out of control. Her job is too important and she doesn’t want to lose it. When she talked about the situation with Barbara, they agreed that she should try to continue ignoring the men. Michelle said she trusts Barbara and is grateful for her advice and encouragement. Barbara, who is about five years older than Michelle, works in marketing for a psychiatric hospital and she is separated from her abusive husband. They met two years earlier when Barbara brought her old Honda in for a paint job.
One Friday a few months ago there were some particularly vicious remarks at the shop and Michelle struggled to control her anger. Barbara had gone to visit her parents so Michelle was alone for the weekend. On her way home after work she decided to have a few beers at a small bar near their neighborhood. She sat alone at the bar drinking beer and trying to forget about her stressful day. About midnight she suddenly slammed her bottle on the bar and jumped to her feet. Angrily she yelled, “I’m a lesbian and I can whip any man in here.” Everyone heard her and the small bar became deathly quiet. No one accepted her challenge so she walked over to the biggest man she could find and punched him in the face. Some of the patrons laughed because she had to reach so high to hit the man. This made her angrier and she started punching the poor man with both fists until the bartender and some of the other men grabbed her and walked her outside. She finally calmed down and allowed an elderly couple to take her home.
The next morning she awoke with a terrible hangover and several cuts and bruises. She realized as she was dressing that her car was at the bar, which was several blocks from her apartment. When she arrived late for work the others wondered what happened, but no one offered to ask any questions. The day went quietly and Michelle was relieved to see it come to an end. She stopped on her way home to get some barbecue and a bottle of beer. Instead of drinking one beer she had three and decided to stop at a bar for more before going home. Remembering the night before she decided to find a bar farther from her neighborhood and unfortunately she picked one with a much rougher crowd. After drinking until about eleven, she once again announced her lesbianism and threatened the men in the bar. Immediately one man laughed loudly and told her to get out of the place before she got hurt. Michelle lunged toward the man without warning and swung at him with her beer bottle. The man noticed in time to duck but the bottle caught him just above his left eye. The bartender immediately rushed out from behind the bar and hit Michelle in the head with a baseball bat. She was sitting on the floor dazed and bleeding when police arrived. After interviewing the bartender and several customers in the bar, they arrested Michelle and took her to the ER in the county hospital. When her wound was stitched and bandaged, she was taken to jail and put in the drunk tank to sober up. Part of this information was taken from her arrest record because she didn’t remember anything after being hit with the bat.
The next morning she was booked and assigned bail. Barbara was still out of town and Michelle didn’t know what to do. She attempted to call Barbara several times and was finally able to reach her about seven in the evening. Barbara came to the jail and made bail and they got home about ten. Michelle had to be in court at 10a.m. so she called her supervisor to tell him she could not come to work. She was surprised when, instead of telling her she was fired, he told her to take care of things and then come in as soon as she could. They also decided to call a lawyer. The next morning her hearing was brief and trial was set for one month later. Her trial was also brief. Michelle’s lawyer negotiated a plea bargain and she entered a plea of guilty in exchange for five year’s probation. As part of the plea agreement she was to avoid drinking alcohol and attend alcoholism counselling. This brought her to my office.
We next went through a series of questions to compile her psychosocial history. She readily answered my questions but I knew she was leaving out details. Her mother was an alcoholic and a marijuana addict. Her father who was also an alcoholic had deserted them when Michelle was four-years-old. They lived in a rough neighborhood on the North Side. Her mother worked as a waitress during the day and went to bars every night. She came home with a different man almost every night, and one of her boyfriends raped Michelle when she was seven. When she told her mother about it she got angry with Michelle, claiming she just wanted to break up her relationship.
Incidents of molestation continued until she was sixteen at which time she ran away from home. She cut her hair, dressed as a boy and managed to get a job as a helper at the automobile paint shop. She quickly learned to be a painter and she was now one of the best in the shop. Most of the friends she made drank a lot so she started drinking to fit in with the group. She found that alcohol took away the memories of childhood abuse and made her feel better about herself. She was soon addicted and sometimes her drinking led to angry outbursts.
Usually the anger was directed toward men and her friends told her that when she got drunk she would yell and scream about her hatred for all men. Since meeting Barbara, Michelle longed to have a normal life but her sense of shame led her to believe that she could never be normal. The only relationships she had seen were those involving her mother and a string of abusive men. The relationship with Barbara was the only normal thing in her life and apparently she was ready to fight anyone who might interfere.
This was a person who had been emotionally and sexually abused for most of her childhood. Shame and guilt consumed her even though she had done nothing to deserve the abuse and certainly had not caused it. She was pessimistic and suspicious of everyone and the only emotions she knew how to express were fear and anger.
Based on her parents’ history of drinking I thought Michelle might have a genetic predisposition to alcoholism. Alcohol and anger certainly made a dangerous combination for her. It was amazing to me that she had been able to hold her job. I knew that she would have to stop drinking before she could work effectively on the other issues in her life. When I told Michelle, she suggested cutting back on her drinking but I informed her that total abstinence is required. I also informed her that she must attend Alcoholics Anonymous in addition to her counseling sessions. We located an AA meeting near her home and I suggested she start this evening. If she found that she was uncomfortable due to her relationship with Barbara I identified a meeting for gay and lesbian alcoholics.
We scheduled our next session and I advised her that I would immediately notify her probation officer if she showed up smelling of alcohol. After she left, I prepared her history and made notes of our session. Then I filed them in a new chart with her name on it and wondered if I would ever see her again.
During the week I prepared a treatment plan to include abstinence, attendance at Alcoholics Anonymous, and weekly counseling sessions. I wanted to help her develop self-esteem and realize that she was not responsible for her abuse. I also wanted her to attend an anger management program. This was an ambitious schedule for Michelle and I expected strong objections from her. After completing the plan, I contacted her probation officer whose name was Kathy. We discussed our session and she asked if I thought Michelle‘s sexual orientation was the cause of her anger. I told her the anger was related to her severe childhood sexual abuse. Kathy proved to be knowledgeable about alcoholism and I thought she was both firm and empathetic. We were in total agreement on the plan I had prepared for Michelle and I was very grateful to have an ally in dealing with this strong young woman.
I was pleasantly surprised when Michelle arrived on time for our next session. She was more relaxed than before and casually dressed. She immediately told me that she came alone because this was something she had to do for herself. I affirmed her decision and asked about her week. She reported no drinking and said she attended AA meetings every evening. It seems she was slightly overwhelmed at the welcome attitude of others at the meetings. Her supervisor at the paint shop, a sixty-year-old man who had suffered his own struggles with alcohol, had talked to her about her legal problem and told her that he knew how the other workers were treating her. He also said that she was the best employee he had and he didn’t want to lose her. She expressed her gratitude for his encouragement and she told me it gave her strength to ignore the insults and control her anger.
After this recap, I presented the treatment plan that I had prepared. I explained the objective of her treatment was to learn how to live sober, and I described how the plan would help her reach that objective. Also I told her that I had discussed this with her probation officer. Michelle resisted when I said that we would have to discuss her family history in detail. I explained that a child who was a powerless victim had formed her thoughts and feelings about abuse. Now that child was an adult and no longer powerless. She could look at her history from an adult viewpoint and make objective and rational decisions about her life. This discussion seemed to make sense to her and she signed the plan. I also told her to enroll in an anger management program and I gave her instructions to contact the program manager.
Without prompting Michelle then began discussing her childhood. Her parents were from north Louisiana and the family had moved to Houston when she was two years old. She could not remember much before the age of three but she said there was yelling and screaming as far back as she could remember. As she grew older she saw her parents drinking and fighting almost every night. She could remember going hungry and dirty for days because her mother would be continuously drunk. Because she was ignored, she learned to take care of herself early on. One morning she awoke to find her father gone and she has not seen him since. She could remember feeling scared because her world had been torn apart. In spite of the fighting, it was her world and losing it made her feel very insecure. In a short time her mother began bringing drunk men home to live with them. Her mother often tried to get Michelle to call her boy friends daddy, but she always ran away from them. I could see the anger in her face as she remembered the drunken men leering at her and calling her “their” little girl.
The time passed quickly as she discussed her childhood and I could see that she was fighting to hold back the tears. This was the first time she had let her guard down and displayed a strong emotion. Then she stopped talking suddenly, as if she was drained of energy. I asked her to talk about her feelings when she was that young child and she identified the fear that she had felt daily. She was unprepared for the stress of talking about her abuse, and I thought she was embarrassed at displaying such emotion. Finally she stiffened and said it was horrible but she had survived and now it was all behind her. I told her she was indeed a survivor. Then I asked if she felt like having a drink and she said no, but I wasn’t convinced. She assured me that she would attend a meeting before going home. We scheduled her next session and as she left I once more wondered if I would ever see her again.
The next morning I received a call from Michelle’s probation officer. She said Michelle called and told her she nearly went to a bar last night but Barbara had talked her out of it. Michelle also said she didn’t want to continue the counseling because it was so upsetting. I told Kathy it was difficult for Michelle because she was looking at her problems as a sober adult and she had never done that before. I also pointed out that sobriety was essential if the counseling was going to be effective. Kathy agreed. She said that she would call Michelle in for an alcohol test and reiterate the terms of her probation. I recommended she also tell Michelle that she had done amazingly well in just two counseling sessions. Kathy thought the young woman was worth our efforts and hopefully Michelle would appreciate it
I understood the obstacles to therapy for Michelle. Many people are reluctant to seek help through psychotherapy because they see it as weakness or an admission that they are crazy or insane. It’s often a long struggle to get a person engaged in the treatment process. In the case of a criminal who is forced to undergo treatment on threat of incarceration the struggle is magnified many times. Trust, which is a corner- stone of therapy, is an immediate issue. Everything the patient says is available to the probation department, which has control of her freedom. Patients know this and it often inhibits dialog. They may resort to lying and playing games with the therapist and therefore never experience any improvement. It takes cooperation and commitment to overcome these obstacles.
On Friday, I was once again surprised to find Michelle back in my office. This time her report of the past week was more serious than before. She verified her near-relapse but stated that she did not drink alcohol. She said that she did attend AA meetings and met a woman who agreed to be her sponsor. There were positive changes at home and at work in the very short time she had been sober. This was good news; however she had serious concerns about continuing therapy. She was still upset due to discussing her childhood and she wondered if it wouldn’t be better to just forget about it. Twice she had dreamed about it and she couldn’t stop thinking of herself as a terrified child. We talked about it and I told her that it would always be with her because it was part of her life. The only way she could eliminate it as a source of shame and guilt and an excuse to drink was to look at it and try to give the shame and guilt to those who caused it. Moving from a victim to a true survivor was not easy; it required her courage and hard work.
I tried to show her that this was an opportunity to accomplish her real potential and establish the normal life she craved. Also I pointed out that she had made a tremendous start and that Kathy and I thought she was a strong woman who could make positive changes in her life. We spent the entire session talking about the advantages of therapy for her future life. At the end she agreed to try. She also told me that Barbara had said some of the same things that Kathy and I had said. I didn’t know Barbara except for the one brief meeting, but I saw that she could be an ally in our recovery project. We scheduled the next session and for the first time I felt confident that Michelle would return. I hoped that she was committed enough to continue.
She did return and for weeks we talked about her childhood before we progressed to relapse prevention. We talked about relapse as a process and I helped her prepare a list of situations that might start that process. The list included anger, loss of her job, loss of her relationship, and death of someone she loved. We discussed what it means to be a survivor and I taught her the difference between aggressive and assertive behavior. Michelle was intelligent and she learned quickly. She made logs of her daily behavior and we reviewed them for signs of progress. Through all of this she remained guarded and almost emotionless as if she expected something bad to happen.
Trust was the most difficult issue for Michelle. She mistrusted nearly everyone except Barbara. Years of being disappointed and abused left her expecting the worst from everyone and this made open communication almost impossible. She always judged people and anticipated their responses, often seeing simple statements as threats or insults. I gave her scripts of conversations in which each person had to clarify every statement and told her to practice this type of communication with Barbara.
As the weeks went by her general mood became more pleasant. When we reached the topic of relationships she was attentive to every word I uttered, as if her life depended on her understanding. I pointed out that a good relationship was dependent on success with all of the other issues that we had discussed. We talked about the importance of mutual trust and open communication in a successful relationship. Each week she seemed more relaxed as she reported improvements in her relationship with Barbara. She even noticed improvements in relationships with co-workers. I spoke with the anger management therapist and she told me that Michelle had made excellent progress. She said in the beginning there were a few incidents of near-violence during role-playing exercises but eventually Michelle began to learn tools to control her anger. The therapist thought that her work in our sessions had helped her to recognize some of her triggers for anger. I was pleased with her progress but I had some concern about her sobriety. It seemed to come too easily and that bothered me. I was sure that she was not drinking because Kathy made random checks, but I knew that recovery could often be fragile.
After nearly three years on her road of recovery Michelle decided on her own to contact her mother. She told me later that she wanted to show her mother that she was not a failure and tell her how angry she was about the abuse. However she learned that her mother had become addicted to heroin and died of an overdose. Michelle was unprepared for the grief she felt. She was ashamed that she had not visited her mother even though she lived just a few miles away. Almost immediately she experienced a strong urge to get drunk but she went home and talked about it with Barbara instead. Later she called her AA sponsor. Eventually she was relieved to realize that she had forgiven her mother, and she purchased a tombstone to replace the small cement marker on her grave. We talked about how this event triggered the relapse process and how she interrupted the process by talking with people she trusted. I thought this was a valuable lesson for her and I knew she was fortunate that it had a happy ending.
In order to evaluate their relationship, I asked Michelle and Barbara to come to a session together. I saw that they were relaxed and comfortable with one another and Barbara remarked about the improvement in their communication. They had moved into a larger apartment in a better part of Houston and formed friendships with several other couples. I could not detect any indication of serious problems between them.
After three years of sobriety Michelle was satisfied with her job and happy in her relationship with Barbara. She had worked hard in our sessions and successfully completed the anger management program. Kathy informed me that she was complying with all of the stipulations of her probation. She had met with Michelle’s employer and with Barbara several times and could not identify any problems. We discussed discharging Michelle from therapy but I wanted to reduce the frequency of our sessions before releasing her. It was important to me to learn how she could do without weekly sessions. I told Kathy that I had several things that would keep me busy or out of town for a while and I suggested scheduling a session for six months later. Kathy was agreeable. She thought it was important to discover any problems before Michelle completed her probation.
At our next session I told Michelle of our plan. She had no objection and told me that she thought it might be time to end therapy altogether because her support from AA gave her confidence that she could continue her recovery. We reviewed briefly some of the issues that she had struggled to resolve and she admitted that she felt some apprehension at the thought of not having a session every week. I saw that as a healthy grounding to her flight of overconfidence. I gave her the name of another therapist in our office and we talked about the importance of calling if she had any problem. With Kathy, Barbara, her AA sponsor, and our therapist available, I was confident that Michelle had ample resources so I scheduled our next session.
I stopped in my office after having been away for nearly four months. After looking through my mail and phone messages I decided to call Kathy to find out how Michelle was getting along. When she answered, I immediately knew from the tone of her voice that something had happened.
“Michelle is in prison,” she said.
“What!” I yelled, then “I’m sorry, what did she do?”
“I know how you feel. About a week after your last meeting she came home after work and found a Dear John letter from Barbara. It turns out that Barbara had been seeing her husband for several months and she was pregnant. In the letter she said she was sorry to disappoint Michelle but she still loved her husband and they were both looking forward to having the baby and starting a new life together. And she added that she and Michelle could never have had a real relationship. Michelle was devastated.”
“I’m afraid to ask what happened next.”
Kathy said, “She told me that she immediately went to a bar and started drinking. After a few beers she started beating the man sitting on the stool next to her with a beer bottle. He was intoxicated and couldn’t defend himself and she nearly killed him before others could stop her. She was convicted of attempted murder and sentenced to life in prison.”
“Did she call anyone for help before she reacted,” I asked.
“No, she didn’t call me or your office or her sponsor. She told me she felt like a helpless victim all over again,”
I felt guilty at having put her on her own and I wondered if she would have called if she thought I was in the office. Memories of our sessions flashed through my mind and I felt weak. I knew I shouldn’t assume responsibility for her behavior but I couldn’t stop feeling guilty. A feeling of helplessness began creeping up from my stomach. I had not realized how emotionally involved I was in Michelle’s treatment.
“I started to call you several times but I just hated to be the one to tell you the bad news,” said Kathy. “We worked very hard for her and I’m just sick that this happened. I keep wondering if I failed somewhere. I guess sexual orientation was a problem for her after all.”
“Yes,” I said, “Barbara’s sexual orientation.”